URDANETA CITY, PANGASINAN COLLEGE OF NURSING

A CASE STUDY ON PNEUMONIA

SUBMITTED BY: Mallar, Adrian G Bsn-3/ Group 4

SUBMITTED TO: Maribel Muriio

I.

PATIENT ASSESSMENT DATA BASE

A. GENERAL DATA
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Patients Name: B.C Address: Pozzurobio, Pangansinan Age: 43 Sex: Female Birth Date: October 2,, 1969 Rank in the Family: Mother Nationality: Filipino Civil Status: Married Date of Admission: August,2013 Order of Admission: Please admin to Medical Ward, secure consent inserted IVF with D5LRS 1L to regulate @ 20-21 gtts/min. Cefuroxime 700 mg IV q8, Paracetamol 500 mg OD PRN. 11. Admitting Diagnosis: PNEUMONIA 12. Attending Physician: Dr. Burcas

B. CHIEF COMPLAINT
According to the patient is experiencing cough fever and dizziness

C. HISTORY OF PRESENT ILLNESS:

D.

PAST HEALTH HISTORY: 1. 2. 3. 4. 5. Childhood Illness: She experienced chicken pox, colds, cough and cold Immunization: Complete Major Illness: None Current Medications: Paracetamol, Mefenamic Acid Allergies: Allergy to Tahong

E. FAMILY ASSESSMENT: Name B.C B.T B.O Relation Pt/Mother Father Son Age 43 40 20 old Sex Female Male Male Occupation None None N/A Educational Attainment College Undergraduate College Undergraduate N/A

. F. SYSTEM REVIEW : 1. HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN Clients perception of health: The client perceives health as if we take care of our self, we will be healthy Clients perception about illness : The client perceives illness as it was really hard to get sick if you dont have money Health maintenance and habits: In maintaining his health as well as his family, they have their check up and sometimes just have selfmedicated of the illness is not severe. Compliance with prescribed medications and treatment: according to the client they always follow the medication and treatment being prescribed. 2. NUTRITIONAL METABOLIC PATTERN: Appetite : The smell and taste can trigger the clients appetite. According to the client, the usual diet is high in fiber and carbohydrates and eats 3 times a day with 2-3 cups of rice and 1 bowl of dish. Usual Daily Menu: - Food : vegetables, fish and meet - Water : pt BC drinks 6-8 glasses of water per day - Beverage : she drinks coke and coffee 3. ELIMINATION PATTER Bowel Habits : According to the client, he usually defecates once a day - Color : Brown - Odor : Aromatic - Consistency : Soft 4. ACTIVITY EXERCISE PATTERN 0 Feeding 1- Dressing 0- Grooming 0 Bathing 0- Toileting 0- Cooking 1 Bed Mobility 1- Home Maintenance Legend: 0 Full Care I Requires use of assistance II Requires assistance and supervision by others III Requires assistance and supervision from another and equipments and devices IV Dependent, Doest participate 5. COGNITIVE PERCEPTUAL PATTERN Hearing : Upon interviewing, Mrs. B.C can perceive sounds and hears all the questions that were being asked

Vision: My client can read books and newspapers clearly. Sensory: Upon applying slight pressure with both arms of Mrs. B.C can differentiate the scent of alcohol from the smell of food. Learning Styles: The client can supervice his learning abilities and level of understanding through watching television and listening in the radio. In tems of decision making, Mrs. B.C approaches her husband they make their decisions together.

6. SLEEP REST PATTERN Sleep habits: Mrs. B.C stated that before she goes to sleep she watches a television program Hours of sleep: She sleeps at 10pm up to 4am Sleeping alteration: Mrs. B.C had alterations in sleeping because he usually work at night. Sleeping aids: her sleeping aids is only watching television 7. SELF PERCEPTION AND SELF CONCEPT PATTERN Felling about current state : Regardless of his situation Mrs. B.C still believed that God will help him in any situation. Description of self: She described herself as kind, loving mother and wife Known capabilities and weakness: As verbalized by the client my weaknesses are my family Self worth: The client sees herself as kind, loving mother and wife

8. ROLE RELATIONSHIP PATTERN According to Mrs. B.C she is doing her responsibility to her son as well as to his husband 9. SEXUALTY REPRODUCTIVE PATTERN Physical and psychological effect of the clients current health status on sexual expression: Mrs. B.C stated that she can still performed sexual activity together with her husband but thers a limitation. 10. COPING STRESS TOLERANCE PATTERN Perception of stress and problems : Mrs. B.C perceives stress as a problem as we can easily solve our problems if we think for the solution Coping method and support system according to Mrs. B.C she prays all the time. 11. VALUE BELIEF PATTERN Values, goals and philosophical belief: According to the client she believes that GOD is always there for us Religious and spiritual beliefs: the client is Roman Catholic and believes that be contented f what GOD gave to you

G.

HEREDO- FAMILIAL ILLNESS 1. Paternal no known illness 2. Maternal no known illness

H.

DEVELOPMENTAL HISTORY Patients Description INTIMACY vs. ISOLATION - It is involves parenting care and offers support and praise for decision making

Theorist

Age

Sex

Erik Erickson

43

Female

Jean Piaget

43

Female

Formal operation thought - First it relates how she really thinks nd - 2 , how she solved/ handled problems in a mature though and reasoning and lastly - On how she accept opinions of significant others Post conventional, Level 3 stages 6 It involves on how an individuals internalized the standards of conduct and how he apply/ put the standards conduct into her life

Lawrence Kohlberg

43

Male

I.

PHYSICAL ASSESSMENT A. General Survey 1. Overall appearance and grooming: The client is conscious and coherent 2. Actual height and weight vs. ideal body weight: Height: 5ft and weight 65 kg. 3. Symptoms of distress: none 4. Posture and gait: The client has a good posture 5. Affect and mood: According to the client he still shows great happiness 6. Relevance and organization of thoughts: She can understand and answer all questions appropriately 7. Vital signs of the day of physical examination Temperature: 37.9 degrees Celsius Pulse rate: 89 beats per minute B. Regional exam- utilize IPPA technique 1. Hair: Upon inspection, Hair are evenly distributed, short and no presence of infection Head : Head is round. 2. Eyes: Upon inspection of the clients eyes, eyebrows are evenly distributed, 3. Nose: there is discharges upon inspection, no cuts, no edema 4. Ears: Symmetrical and no discharges noted upon inspection 5. Mouth and throat: Upon inspection, outer lips are uniform in color, soft and dry. Oral mucosa is also dry. 6. Neck and lymph nodes: The clients neck muscles are equal in size, no visible nodules or masses upon palpation 7. Skin: Brown in color, warm to touch 8. Nails: Fingernail plate shape convex, smooth texture 9. Thorax and lungs: With RR of 34 bpm, fast rhythm breath and has crackles upon inhalation. 10. Cardiovascular: With 89 beats per minute, lub/dub can be heard upon auscultation. 11. Abdomen: no pain upon palpation 12. Extremities: He was able to flex and extend his extremities actively but with weakness noted. Respiratory rate: 35 beats per minute Blood pressure : 100/70

15. Neurological/Cranial nerves: Not performed

II. PERSONAL/SOCIAL HISTORY A. Habits: a. b. c. d. e. Caffeine: She drinks 2 cups every day Smoking: no Alcohol: She drinks alcohol occasionally Tea: Sometimes Drugs: The drug regimen prescribed to her by the doctor.

B. Lifestyle: According to the patient she does the Activities of Daily Living C. Social Affiliation: The patient is obeying the rules and regulation in their barangay D. Rank in the family: Mother E. Travel (within 6 months): The patient dint travel to far F. Educational Attainment: College Undergraduate III. ENVIRONMENTAL HISTORY According to his mother, they are living with her husbands family. Their house is located at the rice field. Its made of raw m aterials like cement and hollow blocks; their using tricycle as their transportation going to market/town which about 5 km away from their house.

IV.

INTRODUCTION

Pneumonia is an inflammatory condition of the lungaffecting primarily the microscopic air sacs known as alveoli. It is usually caused by infection with viruses or bacteria and less commonly other microorganisms, certain drugs and other conditions such as autoimmune diseases. Pneumonia can be a serious threat to our health. Although pneumonia is a special concern for older adults and those with chronic illnesses, it can also strike young, healthy people as well. It is a common illness that affects thousands of people each year in the Philippines, thus, it remains an important cause of morbidity and mortality in the country. Pneumonia is an inflammation or infection of the lungs most commonly caused by a bacteria or virus. Pneumonia can also be caused by inhaling vomit or other foreign substances. In all cases, the lungs , air sacs fill with pus, mucous and other liquids and cannot function properly. The most common cause of bacterial pneumonia in adult is a bacteria called streptococcus pneumonia or pneumococcal. Most viral pneumonias are patchy and the body usually fights them off without

help from medication or other treatments. Pneumococcus can affect more than the lungs. The bacteria can also cause serious infection of the covering of the brain (meningitis ), the bloodstream, and other parts of the body.

V.

ANATOMY AND PHYSIOLOGY

The lungs constitute the largest organ in the respiratory system. They play an important role in respiration, or the process of providing the body with oxygen and releasing carbon dioxide. The lungs expand and contract uo to 20 times per minute taking in and disposing of those gases. Air that is breath in is filled with oxygen and goes to the trachea, which branches off into one of two bronchi. Each bronchus enters a lung. There are two lungs, one on each side of the pumped by the heart throughout the body. The alveoli also take in carbon dioxide, which is then exhaled from the body.

VI. Pathophysiology Virulent Microorganism Streptococcus Pneumoniae Microorganism enters the nose (nasal passages )

Passes through the larynx, pharynx, tracheas

Microorganism enters and affects both airway and lung parenchyma Airway damage Infiltration of bronchi Infectious organism lodges Stimulation in bronchioles Alveolar collapse Increase pyrogen in the body Fever DIFFICULTY OF BREATHING (Productive/ non-productive) Necrosis of bronchial tissues Narrowing of air passage Lung invasion Flattening of epithelial Macrophages and leukocytes Mucus and phlegm production Coughing

VII. Laboratory Test

HEMATOLOGY Test Hemoglobin Result 95 Normal values 130.00 180.00 g/L 0.42 0.52 g/L Significance Decreased hemoglobin levels imply decrease oxygen carrying capacity of the blood A low hematocrit referred to as being anemic caused by loss of blood or dietary deficiency Within normal range Within normal range Within normal values Within normal values

Hematocrit

0.31

Segmenters Lymphocyte Monocyte Platelet

0.59 0.39 0.02 177

0.50-0.70 0.20-0.40 0.00-0.07 150-400 x 10 g/L

IX. DRUG STUDY

Generic Name:Cefuroxime Brand Name:Kefox Drug Classification:Cephalosporin second generation Dosage:750mg SIVP q8 ANST ( - ) Indication: for bone and joint infections
Mechanism of Action Contraindication Adverse Effect o Bactericidal: Inhibits synthesis of bacterial cell wall, causing cell death. Hypersensitivity to cephalosporins and related antibiotics; pregnancy (category B), lactation. o o Erythema multiforme Epidermal necrolysis Nephrotoxicity Pseudomembr anous colitis Side Effects Nursing Consideration

GI: Diarrhea, nausea, antibioticassociated colitis. Skin: Ra sh , pruritus, urticaria. Urogenital: Increased serum creatinine and BUN, decreased creatinine clearance. Hemat: Hemolytic anemia MISC: Anaphylaxis

Before: Determine history of hypersensitivity reactio ns to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated. Lab tests: Perform culture and sensitivity tests before initiation of therapy and periodically during therapy if indicated. Therapy may be instituted pending test

results. Monitor periodically BUN and creatinine clearance.

During: Inspect IM and IV injection sites frequently for signs of phlebitis. Monitor for manifestations of hypersensitivity (see Appendix F). Discontinue drug and report their appearance promptly. Monitor I&O rates and pattern: Especially important in severely ill patients receiving high doses. Report any significant changes. Report onset of loose

stools or diarrhea. Although pseudomembranous colitis (see Signs & Symptoms, Appendix F) rarely occurs, this potentially life-threatening complication should be ruled out as the cause of diarrhea during and after antibiotic therapy. After: Instruct patient to take medication around the clock at evenly spaced times and to finish the medication completely, even if feeling better Advise patient to report signs of superinfection and allergy Instruct patient to notify health professional if fever and diarrhea

Generic Name:Paracetamol Brand Name:Biogesic Drug Classification:Analgesic/ Anti pyretics Dosage:500mg; 1 tab q4 Indication:For fever Mechanism of Action Contraindication Adverse Effects o o Side Effects Nursing Consideration

Paracetamol reduces the synthesis of prostaglandin which are responsible for the mediation of pain and fever

Contraindicated to hypersensitivity to paracetamol

o o o o o o o o

Methemoglobin emia Hemolytic Anemia Neutropenia Thrombocytope nia Pancytopenia Urticaria Hypoglycemic coma Jaundice

Nausea& Vomiting

Report Nausea and Vomiting these are signs of toxicity Take with food or milk to minimize GI upset

Minimal GI upset

Report pain that persists for more than 3 5 day

X. LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY a. Hypertermia related to disease process b. Ineffective airway clearance related to increase mucus production c. Knowledge deficit related to disease process

X. Nursing Care Plan

Assessment

Nursing Diagnosis

Scientific explanation Dengue Hemorrhagic Fever is potentially deadly complication that is characterized by high fever.

Objectives

Interventions

Rationale

PLANNING

S> tatlong araw na akong nilalagnat O> >Flushed warm skin >Increase Temp. of 37.9OC >irritability >Diaphoresis

Hyperthermia related to disease process

Short term: After 4 hours of Nursing Interventions the patient will be maintaining a normal body temperature.

>Establish good working condition with the pt and SO.

>to gain patients trust

Short term: The patients body temperature shall have a maintained normal body

Hyperthermia is an abnormal rise in the temperature of the human body. Normal body temperature is 98.6 OF or 37.5
O

>monitor v/s q 2hours.

>to have baseline data

temperature.

>provide TSB

>to maintain a normal body temperature.

Long Term: After 4 days of NI, the patient will experience no associated >Encourage increase fluid

C. Fever may

>to replace fluid loss

not result only from a

Long Term: After 4days of

disturbance of heat-regulating mechanism of the body but also through disturbances of the blood, the rate of breathing. Indeed there are oral intake during periods of illness will result to further body weakness impairing the patients ability to perform usual routines and ADLs

complications such as seizures etc.

intake

NI, the patient will experience no associated

>Encourage food rich in Vitamin C

>to boost body resistance to infection

complications such as seizures etc.

>provide client safety

>to prevent further injuries

>maintain bed rest

>to preserve energy

ASSESSMENT
Subjective:

DIAGNOSIS
Ineffective airway clearance related to increase mucus production

SCIENTIFIC REASON
Increased mucus production is often caused by an underlying illness. If mucus is the most prevalent symptom, it is usually caused by something simple like allergies or the common cold. Other illnesses that result in excessive mucus production include pneumonia, flu and bronchitis

OBJECTIVES
Short term goal:

INTERVENTION
Independent:

RATIONALE
1.Tachypnea, shallow respiration are usually present. 2.Lowers diaphragm, promoting chest expansion, mobilization and expectoration of secretion.

EVALUATION
Goal half met.

nahihirapan akong huminga, dami ko kasi plema eh

*RR- 26 *Dyspnea *(+)nonproductive cough *Use of accessory muscle

After 3-4 hours of intervention, patient will expectorate secretions effectively and RR will decrease from 26 to normal range of 1620/min.
Long term goal:

1.Assess rate/depth of respiration and chest movement. 2.Elevate head of bed and changed position frequently.

After 4 hours of nursing intervention, patient expectorated secretion and RR decreased from 26/min to 22/min.

After 3 days of intervention, patient will maintain patent airway as evidenced by normal RR.

3.Assist patient with frequent deep breathing exercises.

3.Deep breathing facilitates maximum expansion of Collaborative: the lungs and 5.Administer mucolytics smaller as indicated. airways. (Fluimucil) 4.Fluids aid in mobilization 6.Providedsupplemental and fluids. expectorations (IVF: PNSS) of secretions 4. Encourage increase in fluid intake.

7.Monitor chest Xray, ABG and pulse oximetry results.

5.Aids in mobilization of secretion. 6.Fluids are required to replace insensible loss and aids in mobilization of secretions. 7.Follows progress and effects of disease process.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: anu po ba ang dahilan bakit ako nagkasakit? as verbalized by the patient

Knowledge Deficit related to disease process

After 30 minutes of nursing intervention, the patient will be able to understand about the disease process and to know the needs of the care and treatment without worry

Assess the clients knowledge about the disease Explain the disease process ( signs and symptoms ), identify possible causes. Describe the condition of the client Tell us about treatment program and alternative medicine Discuss lifestyle changes that may be used to prevent complications Discuss about therapies and options

Simplify the explanation to the client

Increase knowledge and reduce anxiety

After 30 minutes of nursing intervention, the patient was able to discuss about the disease process and to know the needs of the care and treatment without worry

Objective: o o o Presence of stress Self focusing Willing to learn

Facilitate intervention

Preventing disease severity

Giving an over view of treatment options that

can be used. Exploration of possible sources that can be used / supported. Review

Instruct when to the ministry Ask the clients knowledge about the disease, nursing procedures and treatment

VII.

ONGOING APPRAISAL The patient shows progressive recovery and is responding well to both medical and nursing intervention. Comfort measures given.

VIII.

DISCHARGE PLAN Medication Instruct the patient to continue the medications if the doctors order

Exercise Diet Advice patient to increase fluid intake Encouraged the patient to eat foods rich in vitamins and minerals Encourage the patient to have exercise daily